All Insurers Licensed to Write Accident and
Health Insurance in New York State ("Commercial Insurers"), Article 43
Corporations and Health Maintenance Organizations (HMOs).

RE:

Coverage for Preventive and Primary Care
Services.

STATUTORY
REFERENCE: New York Insurance Law
Sections 3216(i)(17), 3221(l)(8) and 4303(j).

Chapter
728 of the Laws of 1993 requires that every policy providing medical, major medical or
similar comprehensive type coverage provide coverage for preventive and primary care
services for dependent children to age nineteen.

The legislation sets forth the preventive and
primary care services that must be covered, including well child visits. The schedule of
well child visits, as well as the services to be provided at such visits, are to be in
accordance with the prevailing clinical standards of a national association of pediatric
physicians, as designated by the New York State Commissioner of Health. In addition, the
legislation requires coverage for necessary immunizations as determined by the Insurance
Department in consultation with the Commissioner of Health, including those immunizations
specifically set forth in the law.

By Circular Letter No.3 (1994), the Insurance Department advised
commercial insurers, Article 43 corporations, and HMOs that the standards of the American
Academy of Pediatrics (AAP) had been designated by the Commissioner of Health as the
clinical standards to be utilized in determining the schedule of well child visits and the
services to be provided at such visits. In addition, at that time, the Department advised
that covered necessary immunizations consisted of those immunizations specifically set
forth in the law. Subsequently, after consultation with the Commissioner of Health, the
Insurance Department issued Circular Letter No. 34 (2000) to modify the list of covered
necessary immunizations to include any immunization recommended by the AAP.

The purpose of this Circular Letter is to further modify Circular
Letter No. 3 (1994) insofar as it relates to those necessary immunizations for which
coverage must be provided pursuant to Chapter 728 of the Laws of 1993 and to withdraw
Circular Letter No. 34 (2000), which is superseded by this Circular Letter. Recent
experiences with coverage of the conjugate meningococcal vaccine Menactra or MCV4
necessitated that the Department review the position that it took in its prior Circular
Letters. Specifically, the Commissioner of Health has advised that tying insurance
coverage of a new immunization to recommendation by the AAP may result in a delay in
coverage for some children in New York State. The Commissioner advises that
recommendations regarding the use of new vaccines are usually made first by the Advisory
Committee on Immunization Practices (ACIP). The AAP typically follows later with the same
recommendation. The Vaccines for Children Program, which provides immunizations for
children up to age 19 who are covered by Medicaid or Medicaid Managed Care or are
uninsured, Native American or underinsured, covers all vaccines recommended by the ACIP.
The result is that children in New York State covered by the Vaccines for Children Program
might have access to covered vaccines more quickly than children covered by private health
insurance.

For that reason, and based upon the recommendation of the Commissioner
of Health, the Department has determined that covered necessary immunizations under the
law are those recommended by the ACIP. The Department expects that, should the ACIP amend
its recommended childhood immunization schedule subsequent to issuance to this Circular
Letter, insurers, Article 43 corporations and HMOs will take the necessary steps to
provide coverage in accordance with the ACIP revised schedule, effective as of the date of
the change, without further communication from this Department.

Please direct any questions concerning this Circular Letter to:

Deborah A. Kozemko, J.D.
Supervising Insurance Attorney
New York State Insurance Department
One Commerce Plaza
Albany, New York 12257